Central Oregon docs start project to curb opiate abuse

Daily drug limit standards will take effect in 2016

In 2016, a community standard will limit the daily dose of opiate drugs prescribed for Central Oregon’s Medicaid patients: No more than the equivalent of 120 milligrams of morphine.

It’s a standard that’s already in use in Washington state and other Oregon counties in an effort to rein in the opioid abuse epidemic. Locally, the dosage cutoff is just the modest beginning of a broader community effort by health care providers to chip away at opioid abuse.

“We’re just trying to put our finger in the dike right now with this one metric and one standard that I think everyone can pretty much agree upon,” said Dr. Steve Mann, the president and medical director of High Lakes Health Care in Bend and the physician leading the local effort.

Between 1 in 4 and 1 in 5 patients is misusing prescribed opioid drugs, according to a review of nearly 40 studies on the subject — all but three carried out in the U.S. — released last week in the Journal of the International Association for the Study of Pain. Oregon led the nation in 2010 and 2011 for nonmedical use of prescription opioids, according to a 2013 Substance Abuse and Mental Health Services Administration report.

Central Oregon’s effort is kicking off with support from Central Oregon’s coordinated care organization, which administers care for Medicaid, or Oregon Health Plan, patients. CCO data on Central Oregon’s OHP population were what initially pushed Mann and other providers to launch the opiate project. “We were seeing there were certain patients who were really gaming the system and pushing for higher and higher narcotic doses, beyond those really supported by the evidence,” Mann said, referring to noncancer patients.

At first, the dosage standard will only apply to OHP patients, but in the future, Mann said the plan is for it to extend to all patients, including those on commercial insurance. The standard will be voluntary, but Mann said the group will try in December to get as many providers as they can to agree to the standard, which he said is already in use across the country.

Central Oregon providers report quarterly the number of chronic pain patients they’re seeing who are using opioid drugs. In the coming months, Mann said his group will introduce them to tools to help screen patients for other conditions that might contribute to opioid abuse, such as depression. Throughout the summer and fall, providers will attend a series of educational events aimed at helping them decrease their opioid prescribing.

But several providers pointed out at last month’s Central Oregon Health Council meeting that there also must be a focus on educating and supporting patients as they’re weaned off of opiate regimens. Opioid alternatives to pain relief, such as behavioral support and dietary changes, are not typically funded under OHP.

Megan Haase, a Central Oregon Health Council board member and CEO of Mosaic Medical, a community health center that sees a large proportion of OHP patients, at the March meeting encouraged Central Oregon’s CCO, PacificSource Community Solutions, to expand its funding for pain relief alternatives.

The CCO temporarily funded a multidiscplinary pain clinic based in The Center: Orthopedic & Neurosurgical Care & Research in Bend that offered alternative practices for chronic pain management, such as cognitive behavioral techniques, modified yoga, anti-inflammatory diets and stress-management techniques. Funding for that project eventually ran out and the project ended, said Rick Treleaven, the executive director of Redmond-based BestCare Treatment Services, a drug rehab and alcohol treatment center.

Treleaven, who oversaw the pain clinic, said he’s frustrated that better alternative programs aren’t being funded, but said he understands the local CCO’s budget is restricted by federal policies.

“There are lots of well-researched tools and evidence-based practices far better than prescribing opiate painkillers, but they’re not currently being widely implemented in Central Oregon,” he said.

In Southern Oregon’s Jackson and Josephine counties, where a massive provider-led effort to curb opiate abuse began in 2011, the CCOs have funded alternative treatment programs to opiates, said Dr. Jim Shames, the medical director for the counties’ health departments.

Down the hall from Shames’ office is the experimental, CCO-funded “pain resiliency program” which provides things such as pain reduction movement therapy and behavioral support for people who are decreasing or ceasing opioid use to treat their pain. Limited CCO funding has not proven to be a barrier there, Shames said.

“Our CCOs have taken the lead in helping us develop alternative treatment programs,” he said.

One potential side effect of limiting access to opioid drugs is a potential spike in heroin use. That’s what has happened in Jackson and Josephine counties as opiate abuse declined, although Shames said he thinks the issue eventually will correct itself.

“Until we kind of turn off the spigot and greatly reduce the number of pills in circulation, we’re going to probably continue to see that,” he said. “There is probably going to be a lag time of many, many years before both numbers go down and stay down.”

Treleaven said he expects to see a similar trend here, but said curbing opiate prescribing will be necessary to fight opiate abuse in the long term.

Another problem Treleaven said contributes to opiate abuse is the number of doctors who are overly concerned about addiction among some patients while being unable to detect the true addicts. Doctors also tend to confuse a patient who is physically dependent on opiates with one who is addicted to them, Treleaven said.

“That’s because of the lack of training,” he said. “They can’t read it properly both ways.”

Mann said that’s long been a dilemma and will be a key focus of the education.

5 Responses

Rich irony we’ll help you kill yourself to end terminal suffering, but if your pain is chronic and expected to continue, sorry we can’t give you any opioids. We’ll gladly write an NSAID though, and honor your advance directive if you have a massive GI bleed.

I believe Oregon is an ‘assisted suicide’ suicide state for terminal illness. Rather an oxymoron I think…they won’t treat your chronic pain but if you want to kill yourself because you have a terminal illness, they’ll give you the lethal dose to do it.

“Gaming the system??”, “a dose everyone can agree on?” We are humans, not machines! Different people metabolize at different rates. Oh I how I feel for the poor in Oregon! …… And all their citizens as this is rolled out. I’m terrified just reading this and located about as far as you can get from Oregon in the Lower 48. I only wish I could have 15 minutes of his undivided attention.

I’m in awe at how fast this war on patients is gaining speed. It’s like a huge freight train that has slowly climbed the mountain through the past few years and now it’s going downhill, gaining speed with every second. I never thought the country I was taught to revere would do this to some of its weakest citizens.